Professional Employment Application

SECTION 1: APPLICANT INFORMATION
Full Legal Name:

First NameMiddle NameLast Name
Date of Birth:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:

Area CodePhone Number
E-mail Address:
Referral Source

Other
SECTION 2: POSITION
Position Applying For:
If "Other" - Position Applying For:
Desired Hourly Rate:
Which best describes you:

Other
Date Available to Start

MonthDayYear
Date
Dates/Times Unavailable
Preferred Weekly Hours:*

Other
Age Groups You Are Comfortable Working With (select all that apply):
SECTION 3: EDUCATION
HIGH SCHOOL/GED:
High School Name or GED:
City, State:
Year:
COLLEGE/UNIVERSITY:

(if applicable)
College/University:
Years Attended:
Degree Received:
Major:
Clinical License Information (If Applicable):
License Type (LPC, LMSW, LMSW-C, LLP, LMFT, LP, etc.)License NumberState IssuedExpiration Date
College/University:
Years Attended:
Degree Received:
Major:
Certifications, Licenses, Additional education, Trainings, etc:
SECTION 4: EXPERIENCE & SKILL AREA

Check areas relevant to your background:
Service & Behavioral Health Experience:
Administrative Skills:
SECTION 5: EMPLOYMENT HISTORY
EMPLOYER #1
Rows Date Started Date Ended

Dates worked for
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Salary/Hourly pay:
Supervisor Name & Contact:
EMPLOYER #2
Rows Date Started Date Ended

Dates worked for
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Salary/Hourly rate:
Supervisor Name & Contact:
SECTION 6: BACKGROUND
Have you ever been convicted of a felony?
If yes, explain:
Are you willing to complete the following as a condition of employment?
SECTION 7: REFERENCES
Reference #1 (Name & Phone Number):
Reference #2 (Name & Phone Number):
Reference #3 (Name & Phone Number):
SECTION 8: CERTIFICATION
Name:Date:
SECTION 9: RESUME UPLOAD
UPLOAD RESUME: If you have trouble uploading documents, email document(s) to hr@rbcsupportservices.org

Upload a File

Cancelof
ADDITIONAL INFORMATION:
Thank you for taking time to complete this job application. We will be in contact with you shortly. We look forward to you potentially becoming part of the RBC Support Services Family.

Email: hr@rbcsupportservices.org

Phone: (248) 396-7589

Website: www.rbcsupportservices.org
Should be Empty:

Rows	Date Started	Date Ended
Dates worked for

Rows	Date Started	Date Ended
Dates worked for

SECTION 1: APPLICANT INFORMATION

SECTION 2: POSITION

SECTION 3: EDUCATION

HIGH SCHOOL/GED:

COLLEGE/UNIVERSITY:

SECTION 4: EXPERIENCE & SKILL AREA

SECTION 5: EMPLOYMENT HISTORY

SECTION 6: BACKGROUND

SECTION 7: REFERENCES

SECTION 8: CERTIFICATION

SECTION 9: RESUME UPLOAD